Injured Employee S Checklist

Injured Employee’s Checklist

_____Report injury to supervisor.

_____ Contact your Injury Compensation Specialist at HRO at 301-342-6867 or 301-342-6868 to notify your local Injury Compensation Program Administrator of your injury ASAP.

_____Obtain medical treatment if needed. You have the option to be treated at the Occupational Health Clinic (Dr. Charlot) or from a duly qualified physician of your choice. If an emergency, you should be transported to the closest civilian emergency medical facility.

_____ Obtain Dispensary Permit from supervisor (OPNAV 5100/9) if being treated at Occupational Health Clinic (Dispensary on base). This form is available on the HR web: in the benefits section. Call 301-342-1496 for an appointment to ensure availability of doctor.

_____ If the Occupational Health Clinic doctor is unable to provide necessary treatment, the Clinic will provide you with a light duty letter and CA-20 form to take to your referral doctor.

_____ If you elect to be treated by a physician of your choice advise your supervisor and contact an Injury Compensation Specialist at 301-342-6867 or 301-342-6868 to obtain a CA-16 or CA-20 form and information on the availability of light duty to take to your treating physician.

_____ It is your responsibility to advise your physician of light duty work available. The light duty letter of availability can be found on the HR website at:

_____ Advise treating physician that your condition is job related and that a case number will be provided to their office. Do not use your health insurance plan.

____ Provide completed dispensary form, CA-20/CA-16 form or disability note to Injury Compensation Specialist or supervisor.

_____ Obtain and complete CA-1 form, Federal Employee’s Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation and provide to supervisor immediately. Request witnesses to the injury provide statements/signature as appropriate. This form is available on the HR web: and go to the benefits section.

_____ If you are unable to return to work due to a traumatic injury then you are eligible to elect Continuation of Pay (COP). COP can be granted to you for absence due to disability or obtaining medical treatment for not more than 45 calendar days following the injury. Any such absence must be supported by medical documentation.

_____ If you are temporarily unable to work because of your injury, you need to keep your supervisor and Injury Compensation Specialist informed of your medical condition and return to work status. Please continue to provide updated medical notes to supervisor and Injury Compensation Specialist upon receipt.